Healthcare Provider Details

I. General information

NPI: 1962112045
Provider Name (Legal Business Name): RYANNE MCKAY CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 S 800 W
PLEASANT GROVE UT
84062-4505
US

IV. Provider business mailing address

867 S 800 W
PLEASANT GROVE UT
84062-4505
US

V. Phone/Fax

Practice location:
  • Phone: 801-785-9019
  • Fax:
Mailing address:
  • Phone: 801-785-9019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: